Relationship between utilization of clinical pathway and recording methods for nutrition management/dietary guidancee

Abstract

Purpose: In association with the revision of the medical payment system, enhancing the contents of records to improve patient satisfaction is an important issue that should be prioritized. In this study, a survey was conducted to ascertain nutrition management recording methods and the statuses of clinical pathway usage and current nutrition management records.

Methods: A questionnaire was sent to 113 facilities in June 2015. Responses were obtained from 90 facilities (a response rate of 79.6%). The data were analyzed using IBM SPSS Statistics 22 and evaluated.

Results: Seventy-one facilities adopted the clinical pathway. 58 facilities (81.7%) achieved “standardization of medical care” and 42 facilities (59.2%) achieved “improvement of operations.” Regarding recording methods used in nutrition management and dietary therapy, 86 of 90 facilities (95.6%) used nutrition management plans. The major recording methods were “problem-orientated medical records (POMRs)” and “simplified method”; each was used in 43 facilities (47.8%). As points for improvement in record contents for team care, 60 of 90 facilities (66.7%) responded “information sharing” and 46 facilities (51.1%) responded “utilization in communication between staff members.”

Conclusion: The present study shows that the clinical pathway has been widely adopted by medical facilities, achieving standardization of medical care and improvement of operations. For nutrition management records, further review is necessary, including sharing of information for team care and improvement of the record contents.